California College of Midwives
State chapter ~ American College of Community Midwives

Section 3 H

Minimum Practice Requirements – INTRAPARTUM REFFERAL

~ to define and clarify minimum practice requirements for the safe care of women and infants in regard to INTRAPARTUM PHYSICIAN CONSULTATION, REFERRAL, TRANSFER & EMERGENCY TRANSPORT


h The Midwife shall consult with a physician and/or another professional whenever there are significant deviations (including abnormal laboratory results), during a client’s labor and birth, and/or with her newborn. If a referral to a physician is needed, the Midwife will, if possible, remain in consultation with the physician until resolution of the concern. It is appropriate for the Midwife to maintain care of her client to the greatest degree possible, in accordance with the client’s wishes, remaining present through the birth and resuming postpartum care if appropriate.


A. The following conditions require physician consultation and may require transfer of care. Consultation does not preclude the possibility of a domiciliary labor and birth if, following the referral, the client does not have any of the conditions set out in this section.


Intrapartum Conditions ~ Serious medical/obstetrical or perinatal conditions, including but are not limited to:



a.       prolonged lack of progress in labor, after use of normal midwifery support

b.      abnormal bleeding, with or without abdominal pain; signs of placental abruption including continuous lower abdominal pain and tenderness

c.       significant rise in blood pressure above woman’s baseline with or without proteinuria

d.      maternal temperature greater than 101.6 degrees Fahrenheit, unresponsive to treatment

e.       maternal pulse over 110 and/or significant hypotension

f.        genital herpes outbreak

g.       client’s desire for pain medication

h.       client’s request for transfer to obstetrical care



a.       abnormal FHT baseline -- tachycardia (>>170 bpm for30+ minutes) or bradycardia (<<100 longer than 3 minutes w/o good recovery to normal baseline) 

b.      persistent non-reassuring FHT pattern with diminished variability that is  unresponsive to corrective measure

c.       ominous FHT patterns – variable or late decels of increasing frequency, and/or length and/or depth, or other signs of immediate fetal distress;

d.      thick meconium-stained fluid or frank bleeding with birth not imminent

e.       abnormal or unstable lie

f.        prolapsed cord


3. Emergency Transport: If on initial or subsequent assessment during the 1st, 2nd or 3rd stage of labor, one of the following conditions exists, the midwife shall immediately consult and/or initiate immediate emergency transfer according to the emergency plan if the following conditions exist and document that action in the midwifery record in the hours following the birth.


It should be noted that because of time urgency during certain situations, it may be necessary to institute emergency interventions while waiting for physician response or emergency transport.


a.       prolapsed cord

b.      uncontrolled hemorrhage

c.       preeclampsia or eclampsia

d.      severe abdominal pain inconsistent with normal labor

e.       chorioamnionitis 

f.        ominous fetal heart rate pattern or other manifestation of fetal distress

g.       seizures or unconsciousness

h.       thick meconium or frank blood in amniotic fluid (unless the birth is imminent)

i.         evidence of maternal shock 

j.        presentation not compatible with spontaneous vaginal delivery

k.      laceration requiring repair outside the protocols or scope of practice of the midwife

l.         retained placenta or placental fragments

m.     neonate with persistent pulse rate greater than 160

n.       neonate with persistent respirations greater than 80 

o.      any other condition or symptom which could threaten the life of the mother or fetus, as assessed by a midwife exercising ordinary skill and knowledge.



4. Emergency Exemptions Clause (Sec 2063) The California licensed midwife may deliver a woman with any of the above complications or conditions, or other bona fide emergency, if the delivery is a verifiable emergency and no physician or other equivalent medical services are available. EMERGENCY DEFINED ~ “emergency” means a situation that presents an immediate hazard to the health and safety of the client or entails extraordinary and unnecessary suffering.